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1LDec. 19. 2013 2 : 21PMJ7—:tax—P.GP1. I'll-1-UT. If[U>Sllf[C WCNQ, 301911 P....? ;Sr <br /> 12748 /V:, <br /> 7 — <br /> J-,4L 4 <br /> McCoy Truck Tire Service Canker. Inc. Name: <br /> 1407 Lone Palm Ave_ Address �V76/I X6 <br /> Modesto, CA 95351 CIbyrl�k f d-I) State;t <br /> 209-521.6221 zip: �s/.s Phone:� 2 49-949182 <br /> q <br /> TPID-1274877-01 TPID with Suffix: 00 <br /> Loadpate; Load Type'- ole I Cubio Yard Ton Ll Pound <br /> Decal # ,1-a Ick-up count: <br /> Lloenge state LdDot Code: RWDY [ ]Delivery <br /> REGUUiR TIME ( ] OVERTIME ( )CALL OUT CU8TOMER PO# 4 s'(, <br /> FIAT REPAIRS WHEN.SWITCHES:f `MT/DISMT� <br /> LICENSE NO-� \ rp`VEHICLE MAKE MILEAGEJW VEHICLE NO' �✓� <br /> LOCATION; ( S� � v' ' <br /> RK PERFORMED: MILEAGE IN <br /> - OUT - 9 _ <br /> TOTAL <br /> � . <br /> TIME IN --� � '• ,•�._ <br /> 7T,tA <br /> TIME OUT <br /> _ SIZE MFG, 0 # 7 W6 WHEEL COMMt:NTS .•, . <br /> __._..-_..._..._ ....... . <br /> 3 -- ._...- —........__...... ..._......__.._ <br /> _d <br /> 6 • <br /> B <br /> pllv9r3 S{ natUr a Cu tomer Si nature: ' Date: <br /> Drivers Name riot Customer Name r(nt " <br /> I awtliy that urder pmel[Y Oi r* .g v Or N�1 IlM r,f tlpn I. Iha1 undx Donaly d DN'tlyy ! s Ilws 91ek d arrda IRIS Ir1e MblrRbm ' <br /> D V.�deo about 1.Vw in D1 I am I WAIO f,Al ldM not 11YI Ink ait�n may pro�b0 BOp!�u hn•gyp pp��q M g00��, ���t r�tefrle.lwn o!Iht9 Inrorme�n My <br /> rottAl N 1V1DOP6bh Cr MbY+s101 Vo w-d 71ry outer Rep{etnitlon Wnw�v roeu drY O�M141 u S2G OISO Co(60y.QM Wo4fion w aamMevel.4 prima vo ro 000 <br /> to�tAnlaDorl R�esa�oc! I secmn( and I'1�."meth,d-4 p.sr�aw.uD b S2GOOop�� Y �.r ddatln par eec+�trad fn FvAlajteOOWtA fM�ylnbn 21-i6T. <br /> pv .c4r7nk pe IMIY�up la M.Md Par ACOA00h w Aar a.d.aOlh�d n PUOUc - <br /> Reso,aee Code eeeae,t a�ez <br /> ( )Imported Load ( )Exported Load and Locatlon I Hauler Exemption Status; <br /> Address: ( ]Government <br /> MON: ( LEA Exempt <br /> State' ( ]Aarlcvllurol <br /> Common Carrier <br /> 1.11 N1 pf <br /> . ........�.._.. oatiu.�.iPtcawl�.�.u�,l•'��'�• iq�� �I°' t •'y;.i�"n.!1 _..,_.. ,........r.r.�...:,. . � ,...,.,.,...... , _.__ <br /> Received Time Dec. 19, 2013 2: 31PM Ne. 0911 <br />